Washington Paid Family and Medical Leave applicants use the Medical Certification when they need paid medical leave for their own serious health condition. The provider briefly describes the condition and gives specific start and end dates for the leave needed, then signs a declaration under penalty of perjury. The patient uploads it to their Paid Leave account for ESD's decision.
The patient completes Section 1 with name, date of birth and Paid Leave Customer ID; an authorized health care provider, such as a physician, nurse practitioner, physician assistant, midwife, clinical psychologist, physical therapist, podiatrist, dentist or naturopath, completes Section 2.
Download the current version from the source each time; forms change without notice.
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
ESD lists physicians and osteopathic physicians, nurse practitioners, physician assistants, nurse-midwives and midwives, clinical social workers, clinical psychologists, optometrists, physical therapists, podiatrists, dentists, naturopathic physicians, and chiropractors in limited circumstances. Others are defined in RCW 50A.05.010 and WAC 192-500-090.
Yes. ESD publishes it as a bilingual English and Spanish form, Certificado médico, updated June 2024. The PDF is flat, with no fillable fields, and fits Section 1 for the patient and Section 2 for the provider on a single page.
Cross out the error, write the correction and initial the change. ESD states it cannot accept forms with whiteout. The rule appears in ESD's guidance for health care providers and covers its medical, family leave and pregnancy and birth certifications.